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Inspection Report Number <br /> ion Re O p p <br /> WasteState of aTire Survey & Inspect p _ � <br /> CIWMB 181 New 04104) Survey Form - Page 1 11 <br /> 1143502 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A_-Survey____---_ - _ ---_ <br /> Business Profile Inspection Details <br /> - - - - - - - - <br /> TPID- (� r Inspection Type (Fill one) <br /> Site Suffix: 3 O 5 1 0 I ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier:— �(� n �QC�GL(l n C�L1{Tl 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name {` <br /> i Inspected By Inspector <br /> 1 <br /> Physical Address9 01J &n Cs( -b <br /> �cxm D�jv� - - - ► U <br /> Inspection Date Q � � b <br /> C►�C.�O n r"� g5�o10 U <br /> Time In Time Out <br /> Business Rep TitleAM <br /> (� Q AM <br /> 3 ' v 0 PM PM <br /> -----Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ,yv) <br /> Generator 0 Outdoor <br /> o <br /> 0 Active 0 Passenger 0 Ge <br /> - - - - -- NIS Nle <br /> Closed 0 Altered <br /> GPS Latitude NIA 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned _ 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ---- <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber n_ <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other S01(ce 4eel QL"Gle rs <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 (Required for NOV or EXT) <br /> 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days � <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators e In Compliance - No Violations <br /> 0 0 Other: § —--_ <br /> Comments <br /> �O�f1JL.�n5��bn t�D� USl-)�S �Wf'e�d►�t� 1'� l,(}U) J t�S �. <br /> 1kT�-vf�� -Oj c�tcuS0�"_CUarcSL1, - - <br /> -l I* \ &C 1j_ - t2S dYA-)JfN U"d '1.4—L1 Or U' i C1 Si SS. <br /> Inspection Form Included: Q - eComments Included: OI <br /> k-( <br /> one NumberBusiness Reps Signature Phone Number e S ,i9�at ( g <br /> 'I <br /> - - - 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � \/ X <br /> I E! 11,213 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />